Clinical Utilization Specialist

2 weeks ago

Atlanta, Georgia, United States Sonder Health Plans, Inc. Full time
Position Overview:

The role of the Healthcare Review Nurse is pivotal in ensuring that medical services are delivered with excellence, cost-effectiveness, and adherence to regulations. By systematically evaluating and auditing patient treatment records, the healthcare review nurse plays a crucial role in preventing unnecessary procedures, ineffective treatments, and prolonged hospital stays.

Key Responsibilities:

The primary duties of this position include:
  • Conducting concurrent reviews of patient clinical data for efficiency
  • Continuously assessing preauthorization requests to determine medical necessity
  • Collaborating on discharge planning as part of a comprehensive care team
  • Utilizing critical thinking and expertise to:
    • Promote high-quality care and improved patient outcomes
    • Avoid complications during hospitalizations
    • Advocate for reduced hospital stays when appropriate
    • Engage in discharge planning processes, coordinating with Case Managers and the patient’s care team to ensure timely discharge and continuity of care
  • Facilitating requests for Sub-Acute care, Durable Medical Equipment (DME), Home Health Services, and Transportation for patients
  • Referring cases with quality-of-care issues to the Chief Medical Officer and Quality Assurance Department
Qualifications:
  • Excellent interpersonal and communication skills, with the ability to engage effectively with diverse groups
  • Capability to plan, implement, and assess individualized patient care programs
  • Familiarity with medical billing processes
  • Proficient in Microsoft Office Suite and Google applications
  • Adept at managing a substantial workload in a fast-paced, results-oriented environment
  • Experience in Medicare Managed Care utilization management and relevant regulations
  • Commitment to maintaining knowledge of and compliance with departmental policies, CMS standards, NCQA, AAHC, and applicable Federal and State guidelines
  • Ability to uphold ethical standards in daily operations, demonstrating professionalism and inspiring teamwork
  • Current state licensure as a Practical Nurse (LPN) in good standing
  • At least one year of prior experience in conducting utilization reviews for a Health Maintenance Organization (HMO)
Work Environment:
  • Minimal physical effort required
  • Work setting involves limited exposure to physical hazards
  • The organization employs a hybrid work model based on position requirements and company needs, subject to change
Equal Employment Opportunity:

Sonder Health Plans is an Equal Opportunity Employer. The company is committed to providing equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Sponsorship:

Must be eligible to work in the U.S. without sponsorship.

  • Clinical Utilization Specialist

    2 weeks ago

    Atlanta, Georgia, United States Sonder Health Plans, Inc. Full time

    Position Overview: The role of the Healthcare Review Nurse is pivotal in ensuring that medical services are delivered with optimal quality, cost-effectiveness, and adherence to regulations. By systematically evaluating and auditing patient treatment records, the healthcare review nurse will safeguard against unnecessary procedures, ineffective treatments,...

  • Clinical Utilization Specialist

    2 weeks ago

    Atlanta, Georgia, United States Sonder Health Plans, Inc. Full time

    Position Overview: The role of the Healthcare Review Nurse is pivotal in ensuring that medical services are delivered with excellence, cost-effectiveness, and adherence to regulations. By systematically evaluating and auditing patient treatment records, the healthcare review nurse will prevent unnecessary procedures, ineffective treatments, and prolonged...

  • Clinical Appeals Specialist

    1 week ago

    Atlanta, Georgia, United States Piedmont Healthcare Corporate Full time

    About the Role:Piedmont Healthcare Corporate is seeking a highly skilled Clinical Appeals Specialist to join our team. As a Clinical Appeals Specialist, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key Responsibilities:Conduct detailed...

  • Clinical Appeals Specialist

    5 days ago

    Atlanta, Georgia, United States Piedmont Full time

    Job Summary:Piedmont is seeking a highly skilled Clinical Appeals Specialist to join our team. As a Clinical Appeals Specialist, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key Responsibilities:Conduct detailed reviews of patient medical...

  • Clinical Appeals Specialist

    5 days ago

    Atlanta, Georgia, United States Piedmont Healthcare Corporate Full time

    Job SummaryPiedmont Healthcare Corporate is seeking a skilled Clinical Appeals Specialist to join our team. As a key member of our appeals process, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key ResponsibilitiesConduct detailed reviews of...

  • Clinical Appeals Specialist

    1 week ago

    Atlanta, Georgia, United States Piedmont Healthcare Corporate Full time

    Job SummaryPiedmont Healthcare Corporate is seeking a skilled Clinical Appeals Specialist to join our team. As a key member of our appeals process, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key ResponsibilitiesConduct detailed reviews of...

  • Clinical Review Specialist

    5 days ago

    Atlanta, Georgia, United States Sonder Health Plans Full time

    Job Description:The Clinical Review Specialist role at Sonder Health Plans is to ensure that healthcare services are administered with quality, cost efficiency, and within compliance.By continuously reviewing and auditing member treatment records, the Clinical Review Specialist will ensure members do not receive unnecessary procedures, ineffective treatment,...

  • Clinical Pharmacy Specialist

    2 weeks ago

    Atlanta, Georgia, United States Grady Health System Full time

    Grady Health System provides diverse career opportunities. Whether you are an experienced professional or just starting your journey, a fulfilling role awaits you at Grady.POSITION OVERVIEWThe Clinical Pharmacy Specialist (CPS) is a licensed pharmacist dedicated to leveraging their knowledge, skills, and clinical expertise in a focused area of pharmacy...

  • Clinical Appeals Specialist

    5 days ago

    Atlanta, Georgia, United States Piedmont Healthcare Corporate Full time

    About the Role:Piedmont Healthcare Corporate is seeking a highly skilled Clinical Appeals Specialist to join our team. As a key member of our appeals process, you will be responsible for reviewing and analyzing clinical information from patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key...

  • Healthcare Recruitment Specialist

    1 week ago

    Atlanta, Georgia, United States Clinical Management Consultants Full time

    Job OverviewAn exciting opportunity has arisen for a Healthcare Recruitment Specialist to contribute to the dynamic field of healthcare staffing.Role ResponsibilitiesIn this fast-paced and rewarding position, the Healthcare Recruitment Specialist will lead recruitment initiatives, create engaging employment marketing materials, conduct interviews with...

  • Healthcare Recruitment Specialist

    1 week ago

    Atlanta, Georgia, United States Clinical Management Consultants Full time

    Job OverviewAn exceptional opportunity awaits for a Healthcare Recruitment Specialist to thrive in a dynamic and rewarding environment.This role involves crafting and implementing effective recruiting strategies, producing engaging employment marketing materials, conducting interviews with healthcare professionals, and collaborating with hospital clients...

  • Healthcare Recruitment Specialist

    2 weeks ago

    Atlanta, Georgia, United States Clinical Management Consultants Full time

    Job OverviewAn exceptional opportunity awaits for a Healthcare Recruitment Specialist within a dynamic environment.In this engaging and fast-paced position, the Healthcare Recruitment Specialist will spearhead recruitment strategies, create compelling employment marketing materials, conduct interviews with healthcare professionals, and collaborate with...

  • Clinical Nurse Specialist

    2 weeks ago

    Atlanta, Georgia, United States Emory Health Care Full time

    Position Overview:Join Emory Healthcare as a dedicated Clinical Nurse Specialist, where we support your professional growth with exceptional benefits, valuable resources, and ongoing mentorship. Our environment is designed to help you excel in your career and achieve your aspirations.Benefits: - Comprehensive health benefits starting on day one - Student...

  • Clinical Nurse Specialist

    2 weeks ago

    Atlanta, Georgia, United States NaphCare, Inc. Full time

    NaphCare, Inc. is collaborating with Everhealth to recruit dedicated Clinical Nurse Specialists to become part of our team. We offer various employment options including Full-Time, Part-Time, PRN, and temporary contracts ranging from 8 to 13 weeks. The scheduling for PRN shifts will be determined by site leadership based on coverage requirements and employee...

  • Clinical Oncologist specializing in Sarcoma

    1 week ago

    Atlanta, Georgia, United States American Society of Clinical Oncology (ASCO) Full time

    POSITION: MEDICAL ONCOLOGIST - SARCOMA SPECIALISTORGANIZATION: AMERICAN SOCIETY OF CLINICAL ONCOLOGY (ASCO)The American Society of Clinical Oncology (ASCO) is seeking a board-certified Medical Oncologist with a specialization in sarcoma, dedicated to the management of adult patients suffering from bone and soft tissue malignancies. This role will involve...

  • Clinical Services Authorization Specialist

    2 weeks ago

    Atlanta, Georgia, United States US Tech Solutions Full time

    Job Title: Clinical Services Authorization Specialist Location: Fully remote Duration: 10 months contract Job Overview: The Clinical Services Authorization Specialist will play a vital role in supporting various operational tasks, including but not limited to: making outbound calls, reviewing and processing authorization requests received through...

  • Clinical Systems Optimization Specialist

    2 weeks ago

    Atlanta, Georgia, United States GHR Healthcare Full time

    Clinical Informatics SpecialistOverviewThe Clinical Informatics Specialist is responsible for leading and enhancing the development, improvement, and efficiency of clinical systems and technologies that influence patient care and operational effectiveness across the organization.This role requires a deep understanding of clinical workflows, regulatory...

  • Clinical Systems Optimization Specialist

    2 weeks ago

    Atlanta, Georgia, United States GHR Healthcare Full time

    Clinical Informatics SpecialistOverviewThe Clinical Informatics Specialist is responsible for leading the ongoing enhancement and optimization of clinical systems and technologies that influence patient care and operational efficiency across the organization.This role requires a deep understanding of clinical workflows, regulatory requirements, and quality...

  • Healthcare Utilization Manager

    5 days ago

    Atlanta, Georgia, United States Sonder Health Plans Full time

    Job Description:The Clinical Review Specialist role at Sonder Health Plans is to ensure that healthcare services are administered with quality, cost efficiency, and within compliance.By continuously reviewing and auditing member treatment records, the Clinical Review Specialist will ensure members do not receive unnecessary procedures, ineffective treatment,...

  • Clinical Nurse Specialist

    2 weeks ago

    Atlanta, Georgia, United States Emory Healthcare Full time

    Overview: Experience fulfillment and recognition in your career with Emory Healthcare. We support your professional development through competitive benefits, valuable resources, continuous mentorship, and leadership initiatives tailored for various roles, all within a nurturing environment that empowers you to excel in your career.We offer:Comprehensive...